multiple cerebral infarcts



OVERVIEW

Definition

Multiple cerebral infarcts generally refers to acute multiple cerebral infarcts, a specialized type of cerebral infarction.

It refers to the simultaneous occlusion of arteries from two or more different blood supply systems in the brain during a single episode, and imaging may reveal two or more independent, discontinuous foci of new infarction [1-2].

The blood supply system of the brain is independent of the left and right sides and is divided into anterior circulation (internal carotid artery system) and posterior circulation (vertebrobasilar artery system).

Recurrent cerebral infarction can also cause multiple foci in the brain, but the mechanism of occurrence and manifestations differ from those of acute multiple cerebral infarction and are not presented in this article.

Staging

There is no authoritative typology or classification of acute multiple cerebral infarction; the following classifications are derived from the literature [2].

Classification according to the innervation of the artery in which the infarct focus occurs

The major arteries of the anterior circulation include the anterior cerebral artery, the middle cerebral artery, and some branches of these arteries. The main arteries of the posterior circulation include the posterior cerebral artery and its branches, and the arteries supplying the cerebellum. Accordingly, acute multiple cerebral infarction can be categorized into the following types:

Acute multiple cerebral infarction in one hemisphere of the anterior circulation, where the infarction foci appear in the blood-supplying areas of the anterior cerebral artery and middle cerebral artery on one side at the same time.

Acute multiple cerebral infarction in the posterior circulation with infarct foci in both posterior cerebral arteries, posterior cerebral arteries, and other artery-fed areas on one side.

Anterior circulation acute multiple cerebral infarction of bilateral cerebral hemispheres with infarct foci in bilateral anterior cerebral arteries and middle cerebral arteries.

Acute multiple cerebral infarctions in the anterior and posterior circulation, with infarct foci occurring simultaneously in the anterior cerebral artery, middle cerebral artery, posterior cerebral artery, posterior cerebral artery, and other arterial blood-supplying areas.

In addition, there is a class of symmetrical cerebral infarction, which often occurs in the bilateral thalamus, the head of the caudate nucleus, the nucleus pulposus, and the cerebellar mid-foot infarction.

According to the area of the infarct foci

Infarct foci with a diameter of <1.5 to 2.0 centimeters are called lacunar infarcts. With this criterion, acute multiple cerebral infarcts can be categorized into 2 types:

Type 1: refers to multiple lacunar cerebral infarcts, and imaging may show more than 1 lacunar infarct foci, often suggesting the presence of embolism, vasculitis, or coagulopathy.

Type 2: refers to non-luminal stroke, even though it is usually called acute multiple cerebral infarction. Imaging reveals larger lesions, often suggesting the presence of emboli of cardiac or aortic origin.

Incidence

The number of new strokes in China is about 2.4 million and the number of deaths is about 1.1 million per year, and cerebral infarction accounts for 70% to 80% of all cerebrovascular diseases [3].

There is no authoritative incidence data on acute multiple cerebral infarction, but some studies have shown that acute multiple cerebral infarction accounts for 9.7% to 33.8% of all cerebral infarctions using diffusion-weighted imaging (DWI) with magnetic resonance examination [2].

Etiology

Pathogenic causes

Overall, acute multiple cerebral infarction is a sign of thromboembolism, caused by multiple emboli or fragmentation of 1 embolus.

The etiology is similar to that of patients with conventional cerebral infarction, but the probability of occurrence of each etiology varies slightly.

Cardiac embolism

Various emboli from the heart, carotid artery, aorta and other large vessels enter the main arteries of the brain along with the blood flow, causing acute occlusion or severe stenosis of the vessels, leading to ischemia, hypoxia, and necrosis of the brain tissue.

Common causes include atrial fibrillation, rheumatic atrial fibrillation, coronary artery disease, acute myocardial infarction, left ventricular thrombus, congestive heart failure, dilated cardiomyopathy, and so on.

Systemic factors

Hematologic disorders: coagulation abnormalities (e.g., increased fibrinogen or erythrocyte pressure volume), megaloblastic anemia, thrombotic thrombocytopenic purpura [4].

Metabolic disorders: hyperhomocysteinemia.

Tumors: pheochromocytoma, lung cancer [5].

Immune system disorders: antiphospholipid syndrome [6], eosinophilia, antineutrophil cytoplasmic antibody (ANCA)-associated small vessel vasculitis, polyangiitis.

Other cerebrovascular diseases: cerebral vasospasm, autosomal dominant cerebral arteriopathy with subcortical infarction and white matter encephalopathy (CADASIL) [7].

Atherosclerosis.

Atherosclerosis occurs due to abnormal lipid metabolism, resulting in deposition of lipids on the inner wall of the arterial vessels, forming plaques and narrowing the vessels.

Atherosclerotic lesions lead to disruption of the wall structure and the development of entrapment or hematoma in the arteries, resulting in occlusion or narrowing of the vessel.

If blood supply is not compensated from other sources, it will cause ischemia of brain tissue.

Cerebrovascular variants

In a small number of people, cerebral vascular variation exists, and the distribution of arterial blood supply area is different from normal. For example, the posterior cerebral artery on one side of the brain should normally originate from the basilar artery, which belongs to the posterior circulation. When vascular variation occurs, the posterior cerebral artery emanates from the internal carotid artery, in which case the disease occurring in the internal carotid artery may appear both in the anterior circulation and the infarction in the region innervated by the posterior cerebral artery.

Drug effects

Some studies have reported that sildenafil (Viagra) and tacrolimus can cause acute multiple cerebral infarction [8-9].

Risk factors

The presence of the following conditions is a high risk factor for this disease.

People with heart diseases such as atrial fibrillation, rheumatic atrial fibrillation, coronary heart disease, coronary atherosclerotic atrial fibrillation.

People with blood system diseases, tumors, and immune system diseases.

Suffer from hypertension, hyperlipidemia, diabetes, hyperhomocysteinemia (metabolic syndrome).

Advanced age, chronic smoking, alcohol consumption, family history of stroke.

Obesity, overweight, chronic physical inactivity.

Symptoms

Main Symptoms

The majority of patients with multiple cerebral infarcts present with manifestations attributable to a single blood-supplying system, similar to a single focal cerebral infarct. A few may exhibit symptoms of multiple system involvement, such as decreased strength in the right and left limbs and aphasia combined with left hemiparesis (usually aphasia combined with right hemiparesis), which are commonly seen as follows:

Non-specific symptoms

Headache, dizziness, nausea, vomiting, photophobia.

Movement disorders

Weakness of facial and limb strength and mobility, such as crooked mouth, inability to lift objects, effort or inability to lift, and shuffling in walking.

Complete paralysis of limbs and inability to move can also occur.

Sensory impairment

Sensory loss or loss of sensation in the limbs, with loss of sensitivity to pain and hot and cold stimuli being the most prominent.

This may be accompanied by numbness, pain, burning, or pins and needles.

Symptoms of brain nerve damage

The affected cerebral nerves are different and vary greatly, with the following common manifestations:

Ptosis, downward and outward strabismus of the eyeballs, inability to rotate flexibly, double vision.

Ptosis of the corners of the mouth, gill leakage, shallow nasolabial folds.

Hearing loss, tinnitus, vertigo.

Aphasia.

Mainly the ability to speak, understand and express is affected, common manifestations are as follows.

Can understand what others say, but cannot express themselves.

Not only can you not understand what others say, but you also do not know what you are saying.

Can say what an object is used for when you see it, but cannot name it.

Dysarthria

Manifested by difficulty in vocalization, slurred speech, etc.

Swallowing disorders

Difficulty in eating, choking while drinking, or even inability to eat in severe cases.

Autonomic dysfunction

Difficulty and effort in urination and defecation; urine and stool cannot be self-controlled and flow out by themselves.

Cognitive impairment

Memory loss, inattention, reduced ability to learn new knowledge and master new skills, inability to calculate, and even development of vascular dementia.

Disorders of consciousness

It can be manifested as different degrees of consciousness disorder, and the common manifestations are as follows.

Drowsiness: fall asleep automatically from time to time, but can be awakened, wake up with normal consciousness, and continue to fall asleep after stopping the stimulation.

Somnolence: in a deeper state of sleep, more difficult to wake up.

Delirium: disorganized behavior and inability to concentrate.

Coma: Entering a state of deep sleep, unable to move on its own, and unresponsive to external stimuli such as pain and sound.

Complications

Cerebral edema, brain herniation

The most common complication, swelling of the infarct site and surrounding brain tissue, increase in brain volume.

Early symptoms are nausea, vomiting, drowsiness or unresponsiveness.

In severe cases, irregular or sudden respiration and coma may occur.

Hemorrhagic transformation

Hemorrhage resulting from the restoration of blood flow to the vessels in the ischemic area after acute infarction.

It manifests as aggravation of the original limb paralysis, impaired consciousness and other symptoms.

Digestive tract bleeding

Injury, bleeding and ulceration of the digestive tract mucosa caused by stress reaction and the use of antiplatelet aggregating drugs.

The symptoms include black tarry stools and vomiting of coffee-colored liquid.

Secondary Epilepsy

Damage to brain tissue results in sudden abnormal discharges of nerve cells, which may lead to epilepsy.

This may manifest as generalized convulsions, apnea, cyanosis of the face and lips, and foaming at the mouth.

Infection

Lung, urinary tract, and skin infections can occur due to prolonged bed rest due to paralysis, swallowing disorders, aspiration, weakness in coughing up sputum, poor urination, and inadequate cleaning.

Symptoms such as fever, cough, sputum, cloudy urine, rash, pustules, etc. are manifested.

Lower extremity deep vein thrombosis/pulmonary embolism

Lower extremity venous thrombosis can be caused by limb paralysis and prolonged bed rest.

It is characterized by swelling of the limb, slightly high local skin temperature, and in severe cases, distal necrosis of the limb.

Dislodgment of thrombus may cause pulmonary embolism, resulting in life-threatening respiratory distress, cyanosis, coughing and hemoptysis.

Consultation

Department of Medicine

Neurosurgery

If symptoms such as limb weakness, numbness, and poor speech occur, it is recommended to consult a neurosurgeon promptly. Neurology or Interventional Radiology may also be consulted.

Emergency Department

If you experience symptoms such as unconsciousness, seizures, or difficulty breathing, it is recommended that you go to the Emergency Department or call the 120 emergency number as soon as possible.

Preparation for medical treatment

Preparation for medical treatment: registration, preparation of documents, and common problems.

Tips for seeking medical treatment

Try to keep a record of symptoms, duration, etc., so that you can give your doctor more information.

If you have the habit of monitoring and recording your blood pressure and blood glucose every day, you can provide the records to the doctor.

Patients with mobility problems and rapid changes in condition need to be accompanied by their family members and avoid driving or riding to the doctor on their own.

Preparation Checklist

Especially need to pay attention to the time of onset of symptoms, special performance, etc.

Any headache, dizziness, nausea or vomiting?

Are there any weakness or numbness in the limbs?

Are there any speech problems or slurred speech?

Choking on water, incontinence?

Any drowsiness, lethargy, coma?

Has anyone in the family suffered from cerebrovascular disease, such as cerebral infarction, cerebral hemorrhage?

Are there hypertension, hyperlipidemia, diabetes mellitus, atrial fibrillation, coronary heart disease, hematologic disorders, tumors, immune system disorders?

Is there any high salt, high sugar, high fat diet, obesity, lack of exercise?

Any history of long-term smoking or alcohol consumption?

Test results in the last six months, which can be carried to the doctor

Laboratory tests: complete set of blood biochemistry, liver and kidney function, coagulation test.

Imaging tests: cranial CT, cranial MRI

Other tests: transesophageal echocardiography, transcranial Doppler ultrasound, angiography, electrocardiogram, etc.

Medication used in the last 3 months, if available in a box or package, carry it to the doctor’s office

Blood pressure-lowering drugs: nifedipine, captopril, verapamil.

Blood sugar-lowering drugs: metformin, insulin, glibenclamide.

Lipid regulators: Atorvastatin, Simvastatin, Probucol, Benzafibrate.

Antiplatelet aggregating drugs: aspirin, tegretol, clopidogrel.

Anticoagulants: warfarin, rivaroxaban.

Others: sildenafil (Viagra), tacrolimus.

Diagnosis

Diagnosis is based on

Medical history

Family history of cerebrovascular disease.

There are underlying diseases such as hypertension, hyperlipidemia, diabetes mellitus, atrial fibrillation, coronary artery disease, hematologic disorders, neoplasms, and immune system disorders.

Have high salt, high sugar, high fat diet, obesity, lack of exercise.

Have a history of long-term smoking or alcohol consumption.

Clinical manifestations

Manifestations include headache, vomiting, limb weakness, sensory loss, speech and swallowing disorders, and consciousness disorders.

Laboratory Tests

Main items: blood glucose, blood lipids, homocysteine, coagulation, etc.

Purpose of examination: To detect the presence of underlying diseases, causes of disease, and overall physical condition.

Precautions: Some items require fasting and regular review.

Imaging

To detect stenosis and occlusion of large arteries, assess collateral circulation and monitor microemboli, and assess the condition of cerebral blood circulation.

It can show atherosclerotic plaques, stenosis and occlusion of blood vessels.

Ultrasonography is economical, convenient, non-invasive and repeatable, but accuracy is greatly affected by the experience of the operator.

It can clearly visualize the structure of the heart and thus determine the presence of emboli, patent foramen ovale, and other lesions in the atria and ventricles.

The ultrasound probe is placed into the esophagus to explore the deep structure of the heart from the back of the heart forward at a close distance, thus avoiding the interference of the chest wall, gas in the lungs and other factors. The image is clearer and the result is more reliable.

Note: Patients with severe inflammation, ulcers, or space-occupying lesions in the pharynx and esophagus should not undergo this test.

MRI can detect ischemia and infarction in various regions of the brain, especially for the acute stage, and can show the lesion area within a few hours of the onset of the disease, and the detection rate of lesions is better than that of CT examination [10].

MRA can dynamically display the direction of blood flow, and the display of collateral circulation is more intuitive.

Precautions:

Plain CT quickly distinguishes cerebral infarction and cerebral hemorrhage.

CTA can show the characteristics of vessel lumen size, morphology, blood flow, wall, etc., and can also clearly observe the relationship between blood vessels and surrounding tissues.

Precautions:

Electrocardiography

ECG is one of the main tests to confirm the diagnosis of atrial fibrillation. An ECG should be performed whenever there is a suspicion that the patient’s onset is related to atrial fibrillation.

The specific manifestation of atrial fibrillation is the disappearance of normal P-waves, which are replaced by atrial fibrillation waves (f-waves) of different sizes and morphology, with a frequency of up to 350-600 beats/min. The rhythm of the QRS wave clusters is completely irregular, resulting in absolute irregularity of the R-R interval.

Note: 24-hour ambulatory electrocardiographic monitoring (Holter) may also be necessary if the routine electrocardiogram does not show an abnormal presentation.

Differential Diagnosis

Cerebral hemorrhage

Similarities: both have headache, vomiting, and impaired consciousness.

Differences: The onset of cerebral hemorrhage is more rapid, with symptoms reaching a peak within minutes or hours. Disorders of consciousness are more common and more severe, with high-density foci in the brain parenchyma on CT scan, cerebrospinal fluid may be bloody, and increased blood pressure is obvious.

Intracranial space-occupying lesions

Similarity: headache, dizziness, weakness of one side of the limbs and other symptoms.

Differences: intracranial space-occupying lesions are common in brain tumors and cysts, which may have acute onset but tend to develop in a chronic and progressive manner.

Multiple sclerosis

Similarity: both can present with limb weakness, numbness, facial paralysis.

Differences: Multiple sclerosis is most common in middle-aged women, and the symptoms can be recurrent and remission; the lesions in the cranial MRI are mainly white matter lesions, which can be accompanied by optic nerve and spinal cord lesions. Special antibodies and immune complexes can be found in the cerebrospinal fluid.

Treatment

Aim of treatment: improve cerebral blood supply, correct or relieve the symptoms of cerebral ischemia, actively prevent and treat complications, and avoid recurrence.

Treatment principle: Intravenous thrombolysis and surgical treatment in the acute stage, and medication and rehabilitation in the recovery stage.

General treatment

Bed rest, cardiac monitoring, close monitoring of consciousness, pupil, pulse, respiration and blood pressure changes.

When coma and respiratory difficulties occur, timely oxygen intake, tracheal intubation and ventilator-assisted ventilation can be performed.

Suspend eating and drinking if vomiting.

Nutritional support can be provided through nasal feeding tube or intravenous fluid route when there is swallowing disorder.

Avoid forceful defecation and coughing, when defecation is laborious, laxatives can be given to evacuate the stool.

Keep the skin clean, turn over regularly, and use air cushion or soft cushion to prevent pressure ulcers.

Use long compression stockings and pneumatic compression devices to prevent deep vein thrombosis of the lower limbs.

When fever occurs, physical cooling can be supplemented by placing ice packs in the groin, armpits and neck, or using cooling beds or cold mattresses.

Medication

Intravenous thrombolysis

Purpose of medication: Intravenous thrombolysis is currently the most important measure to restore blood flow [10].

Common drugs are alteplase (rt-PA).

Precautions:

Antiplatelet aggregation therapy

Purpose of medication: to prevent new thrombosis, to prevent the proliferation and expansion of intravascular thrombi, and to reduce the risk of recurrence.

Common drugs: aspirin, clopidogrel.

Precautions:

Lipid-lowering drugs

Purpose of treatment: regulate blood lipids, stabilize atherosclerotic plaques, reduce the risk of plaque detachment.

Commonly used drugs: statins (Rosuvastatin, lovastatin, etc.), nicotinic acid drugs (niacin, acyclovir, etc.), beta drugs (fenofibrate, benzapentamide, etc.).

Precautions:

Neuroprotective therapy

Purpose of medication: improve cerebral microcirculation, reduce brain damage.

Commonly used drugs: butalbital, edaravone, etc.

Precautions:

Other medications

Reduce intracranial pressure and cerebral edema: use mannitol, glycerol fructose, furosemide, etc. to reduce intracranial pressure.

Anticoagulation therapy: patients with atrial fibrillation can be treated with warfarin, dabigatran, rivaroxaban and apixaban.

Treatment of underlying diseases: patients with hypertension can be treated with labetalol, nicardipine, nifedipine, etc.; patients with diabetes can be treated with insulin; patients with autoimmune diseases can be treated with prednisone, dexamethasone, immunoglobulin, etc.

Surgery

Surgery for cerebral infarction

For patients with severe cerebral edema, elevated intracranial pressure, and brain herniation, surgery can reverse the occupying effect, reduce brain tissue displacement, lower intracranial pressure, and improve cerebral perfusion pressure, thus preventing further brain damage.

Commonly used surgical procedures include debulking decompression, hemodialysis, and internal decompression.

Precautions:

Surgical treatment of atrial fibrillation

Surgical treatment is available for patients who have poor or intolerant drug therapy and have significant cardiac symptoms.

Commonly used surgical procedures include radiofrequency ablation surgery, maze surgery, and percutaneous left auricular blockade.

Rehabilitation treatment

Similar to the principles and methods of treatment for patients with conventional cerebral infarction, individualized rehabilitation programs are formulated according to the functional deficits that occur after the condition is stabilized.

Exercise therapy

During the bed-ridden period, the upper and lower limbs can be moved with the assistance of the therapist to the extent that they can be tolerated, which can prevent muscle atrophy, avoid muscle tension and stiffness, and maintain the range of joint movement; when the patient has a certain degree of motor ability, he or she can turn over, get up, remain seated, stand up, and walk under the guidance of the therapist.

To apply stimulation to the skin and joints, such as touching, ice-warm water alternating temperature stimulation, squeezing, weight bearing, and so on.

To perform training such as deep breathing, blowing up balloons, coughing and abdominal breathing.

Ease swallowing disorders through training such as swallowing small amounts of food by changing eating positions, adjusting the nature of food, etc.

Train patients to respond correctly from listening, speaking, reading and writing to improve their speech; train the movement of muscles in the face and throat to improve the clarity and fluency of pronunciation.

Train the patient’s memory, calculation and thinking skills by memorizing numbers, doing math and reasoning problems.

Practical daily life movement training such as dressing, getting up, eating, washing, and handling urine and feces.

Biofeedback and neuromuscular electrical stimulation therapy to restore muscle strength and motor function.

Traditional Chinese Medicine (TCM)

Similar to the principles and methods of treatment for patients with conventional cerebral infarction, it is often based on the principles of clearing heat and removing blood stasis, detoxifying the collaterals, resolving phlegm and clearing the bowels, and waking up the brain and opening the mind [12].

Medications can be used, such as purging phlegm soup, antelope horn soup with subtractions, tianma hooker drink with subtractions, dachengqi soup, thrombotoxin, anguo niu huang pill, niu huang qin xin xin pill, and so on.

In addition, acupuncture, moxibustion, tuina and other treatments can also be used.

Prognosis

Cure

Overall, the prognosis of acute multiple cerebral infarction is poorer than that of single-focal infarct foci, and the risk of cerebral infarction recurrence and relapse is higher [13-14].

The prognosis mainly depends on the size and location of the infarct foci, not the number of infarct foci.

Underlying disease conditions such as tumors, severe hematologic disorders, and autoimmune disorders also affect prognosis [15].

Hazards.

Limb paralysis, cognitive and speech disorders, and urinary and fecal incontinence seriously affect the quality of life of patients.

Patients presenting with impaired consciousness may not improve in the long term, and some may become vegetative.

Severe and irreversible disability can bring great psychological barriers, cause mental illness, and increase the burden of family and society.

Day-to-day

Daily Management

Dietary management

Balanced diet, choosing a variety of food to achieve reasonable nutrition to ensure adequate nutrition and appropriate body weight.

Use less-salt and less-oil cooking methods, such as steaming, boiling, mixing, water-skimming, simmering, etc., for easy digestion and absorption.

Eat more vegetables, fruits and whole grains. Vegetables can be cooked in less time or cold.

Avoid foods that contain a lot of salt, such as salted meat, salted vegetables and other foods.

Avoid spicy and stimulating foods or drinks, such as chili peppers, curry, coffee and strong tea.

For those who have difficulty swallowing, pureed or pasty foods need to be consumed according to the diet prescribed by your doctor.

Stop smoking and drinking.

Life management

Appropriate exercise can be done under the guidance of physician after the disease is stabilized.

Blood pressure, blood sugar, blood lipid, coagulation and other indicators should be strictly controlled to reach within the ideal range.

Avoid exertion and take rest.

Avoid fluctuation of blood pressure due to excessive emotional fluctuation, which may aggravate cerebral ischemia.

Psychological support

Patients themselves should minimize anxiety, maintain a stable, positive and optimistic mental state, and establish confidence in overcoming the disease, which is helpful to the recovery of the disease.

Family members should care more about the patient and increase communication and exchange with the patient.

If necessary, seek help from professional psychological practitioners.

Disease monitoring

Monitor changes in symptoms such as state of consciousness, muscle weakness and sensory loss on a daily basis.

Monitor and control blood pressure, lipids, blood sugar, and coagulation.

Gastrointestinal bleeding may occur during treatment and should be observed for abdominal pain and darkened stools.

Follow-up review

Follow the doctor’s instructions for regular review, usually 1 to 3 months need to review, in order to adjust the treatment program.

The main review items include blood lipids, blood glucose, homocysteine, etc., transcranial Doppler ultrasound, transesophageal echocardiography, and cranial magnetic resonance examination.

Prevention

Patients with multiple cerebral infarctions follow the same principles of stroke prevention [16].

For those who have not developed

Actively control the underlying disease to avoid multiple cerebral infarction.

Abstain from smoking and alcohol, regular work and rest, ensure sleep, and strengthen exercise.

Diversify the types of daily diet, pay attention to low-salt, low-fat, sugar control.

Obese and overweight people should lose weight.

For those who have already had the disease

On the basis of the above preventive measures to avoid recurrence through drugs, surgery and other methods.

Commonly used drugs: aspirin, clopidogrel, atorvastatin, warfarin, etc.

Surgical interventions: angioplasty, stenting, carotid endarterectomy, etc.